Provider Demographics
NPI:1114085974
Name:FIRST LADY THE SPECIALY SHOP FOR WOMEN INC
Entity Type:Organization
Organization Name:FIRST LADY THE SPECIALY SHOP FOR WOMEN INC
Other - Org Name:POSITIVELY BEAUTIFUL BOUTIQUE & GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/GM
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOGHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-899-8881
Mailing Address - Street 1:348 TRANE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-6052
Mailing Address - Country:US
Mailing Address - Phone:865-240-0098
Mailing Address - Fax:888-606-4866
Practice Address - Street 1:713 E EMORY RD STE 101
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37938-4685
Practice Address - Country:US
Practice Address - Phone:865-362-5937
Practice Address - Fax:865-622-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4091915OtherBCBS
TN5231130001Medicare ID - Type Unspecified